Emerg Med Clin N Am 25 (2007) 679–694

Evaluation and Management

of Neck Trauma
Niels K. Rathlev, MD*, Ron Medzon, MD,
Mark E. Bracken, MD
Department of Emergency Medicine, Boston Medical Center, Boston University School
of Medicine, One Boston Medical Center Place, Boston, MA 02118, USA

Blunt and penetrating trauma to the neck can result in life-threatening in-
juries that demand immediate attention and intervention on the part of the
emergency physician and trauma surgeon. This article provides a literature-
based update of the evaluation and management of injuries to aerodigestive
and vascular organs of the neck. A brief review of cervical spine injuries
related to penetrating neck trauma is also included. Airway injuries chal-
lenge even the most skilled practitioners; familiarity with multiple ap-
proaches to securing a definitive airway is required because success is not
guaranteed with any single technique. Esophageal injuries often present in
subtle fashion initially, but more than a 24-hour delay in diagnosis is asso-
ciated with a marked increase in mortality. In total, 7% of injuries to critical
structures of the neck involve major arterial vascular structures, including
the subclavian and internal, external, and common carotid arteries [1]. Ar-
terial injuries are a major source of morbidity and mortality for these
patients. Currently, spinal cord injuries and thrombosis of the common
and internal carotid arteries account for 50% of all deaths attributable to
blunt and penetrating neck trauma.

Aerodigestive injuries
Epidemiology
Penetrating injuries to the airway and digestive tract are primarily caused
by gunshot wounds and stab wounds. Wounds requiring operative repair
are extremely rare. In one series of 12,789 consecutive trauma patients

* Corresponding author.
E-mail address: nrathlev@bu.edu (N.K. Rathlev).

0733-8627/07/$ - see front matter Ó 2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.emc.2007.06.006 emed.theclinics.com
680 RATHLEV et al

over an 8-year period, only 12 (0.09%) patients had aerodigestive injuries

[2]. Other studies place the injury rate closer to 5%. It is therefore difficult
to conduct large-scale studies to determine optimal diagnostic and manage-
ment decisions, and the existing literature reflects this.
Blunt trauma composes only about 5% of all neck trauma [3]. Aerodiges-
tive injuries are rare but potentially life threatening and require a high index
of suspicion to diagnose and treat properly. During a 9-year period (1988–
1996) at one level 1 trauma center, 12,789 trauma patients were seen in the
emergency department, of whom only 16 (0.13%) had tracheobronchial in-
juries [2]. Airway occlusion is the most immediately recognizable and rap-
idly fatal injury, but many other injuries to the aerodigestive tract present
more insidiously and prove no less fatal.
The most common mechanism causing blunt trauma to the neck is the
motor vehicle collision [4]. These injuries typically result from rapid acceler-
ation and deceleration, or direct blow of the anterior neck on the steering
column or dashboard crushing the trachea at the cricoid ring and compress-
ing the esophagus against the cervical vertebrae. They can also occur from
increased intrathecal pressure against a closed glottis from improper seat
belt use [3].
Strangulation results from hanging, ligature suffocation, manual chok-
ing, and excessive manipulation. The usual mechanism of death in hangings
occurs from pressure on the jugular veins, preventing venous return from
the brain and backing blood up in the brain, resulting in a loss of conscious-
ness. The now unconscious patient falls with all of his weight against the
ligature, compressing the trachea and restricting airflow to the lungs. Irre-
versible asphyxiation follows in minutes [5]. Choke holds, no longer pro-
moted in police training, typically generate greater force and injure by
carotid artery occlusion or carotid body reflex. Clothesline injuries occur
in sports (football tackle, martial arts), all-terrain vehicles, motorcycles,
and snowmobiles. Direct blows by fists, feet, and other blunt weapons,
and excessive cervical manipulation account for the remainder [6,7].

Clinical presentation
Any history that the patient is able to communicate about the mechanism
of injury should be elicited. If the patient arrives by emergency medical ser-
vices they should have information, as may friends or family who come with
the patient. Clinical symptoms range from patients who have no symptoms
to those who have life-threatening airway compromise or profound shock.
Penetrating injuries to the airway may present with dyspnea, hoarseness,
and cough. Conversely, progressive airway obstruction from an external
source, such as an expanding hematoma, often presents with abnormal respi-
ratory patterns, stridor, dysphonia, tachypnea, or cyanosis. In 1985, Kelly and
colleagues published a 20-year study that examined 106 consecutive patients
who had neck trauma (100 penetrating and 6 blunt); all 80 patients who had
 EVALUATION AND MANAGEMENT OF NECK TRAUMA 681

tracheal injuries had signs of airway compromise in the emergency depart-

ment. These signs included tachypnea, dyspnea, cyanosis, subcutaneous
emphysema, and an abnormal respiratory pattern. Hemoptysis was an unreli-
able sign of serious injury and patients who had major vascular or tracheal
injuries rarely survived [8]. Other investigators have found that breathing dif-
ficulties may not be present initially. Other presenting features include voice
alteration, stridor, drooling, cervical subcutaneous emphysema, or crepita-
tion, dyspnea, and distortion of the anatomy of anterior neck, including
loss of normal landmarks, asymmetry, flattened thyroid prominence, and tra-
cheal deviation [9].
The evaluation of blunt neck trauma begins with the airway. Greene [10]
evaluated the clinical signs of laryngeal fracture according to anatomic loca-
tion. Injuries above the glottis presented with cervical emphysema, progres-
sive airway obstruction, palpable thyroid cartilage disruption, dysphagia,
and hoarseness. Although injuries located below the glottis were not associ-
ated with swallowing difficulties and did not have early signs of airway com-
promise, they did present with hemoptysis and persistent air leak from the
endotracheal tube in intubated patients [10].
Early detection of penetrating esophageal injuries remains difficult. The
average delay to diagnosis from time of injury is usually many hours
when using a selective approach, and the resultant morbidity and mortality
are significant [11,12]. Although more than 90% of patients survive if the
injury is detected within 24 hours, the survival rate drops precipitously after
this time, usually from infectious complications, such as mediastinitis. Clin-
ical findings of dysphagia, odynophagia, drooling, and hematemesis are
approximately 80% sensitive for injury [10]. Clinical signs of esophageal in-
jury are infrequently present, although crepitus in the neck or a sucking neck
wound may be found on physical examination. Subcutaneous emphysema
may be seen on plain radiographs.
Blunt esophageal injuries are uncommon. Dysphagia, blood in oral gas-
tric and nasogastric aspirate, and crepitus are all sign of blunt esophageal
rupture. In some cases there may be no initial signs of significant injury.
This phenomenon is particularly relevant in the elderly population. Keogh
and colleagues [13] describe two cases in which minor neck trauma caused
significant airway compromise from delayed neck hematomas. Both patients
were anticoagulated with warfarin.

Diagnostic evaluation
Penetrating injuries
Stable patients are approached from a selective set of criteria that are out-
lined in detail in Fig. 1. Lateral neck plain films and chest radiographs are
useful initial tests. Subcutaneous emphysema is often the most common pre-
senting sign in significant injury to the aerodigestive tracts [14]. In patients
who have airway disruption, the surgical anatomy of the rupture creates
682 RATHLEV et al

Diagnostic Algorithm for Penetrating Neck Trauma

Penetrating neck trauma

Stable Unstable
-hemorrhagic shock
-evolving stroke
-expanding hematoma
-unstable airway
Physical exam Surgical exploration
AP Chest x-ray
AP/lateral soft tissue neck x-ray
normal abnormal

Observation
Zones
I, II, III

MDCT/Conventional Angiography

Suspicion of
Aerodigestive
Vascular injury
injury Surgical exploration
Esophagoscopy
Laryngoscopy
No injury injury

Observation Surgical exploration

Fig. 1. Diagnostic algorithm for penetrating neck trauma.

predictable patterns of air leak on plain films. Patients who have laryngeal
transection may have gross, deep, and superficial cervicofacial emphysema,
whereas patients who have tracheal rupture often present with massive
mediastinal and deep cervical emphysema without pneumothorax [15].
The improvement in speed and resolution of images by multidetector com-
puted tomography (MDCT), including the 16-row multiplanar reconstruc-
tions, has had a significant impact on the adoption of selective management
of penetrating neck injuries. CT can accurately identify extrapulmonary air,
directly visualize tracheal wall disruption and signs of transtracheal balloon
herniation in intubated patients, and locate extratracheal endotracheal tube
position [16]. In cadaveric intubations with tracheal disruption, CT images
closely match those compared with matched live cases, and equally good re-
sults comparing CT images to bronchoscopic images confirm the accuracy
 EVALUATION AND MANAGEMENT OF NECK TRAUMA 683

of CT. The reconstructions also help the surgeon to choose the optimal surgi-
cal approach. These studies also note that it takes an extreme amount of pres-
sure to rupture the tracheal rings in cadavers, suggesting it would be unlikely
for routine endotracheal balloon inflation during intubation to cause addi-
tional airway compromise in penetrating neck injuries [17,18].
Stable patients who have suspected airway injury should be evaluated
with a combination of careful physical examination, plain films, CT, and
bronchoscopy, depending on the institutional approach. Although three-
dimensional (3D) reconstructive CT is extremely good at identifying and
locating tracheal injuries, bronchoscopy must still be considered the gold
standard test.
Barium swallow, flexible endoscopy, and rigid endoscopy all have sensi-
tivities approaching 90%. In one study the combination of rigid endoscope
and barium swallow found 100% of esophageal injuries [19]. MDCT may
demonstrate free air in the neck caused by esophageal perforation or rupture
(Fig. 2); however, this diagnostic modality cannot presently be considered
a gold standard because large-scale studies have not been performed to mea-
sure its sensitivity for this potentially catastrophic entity. The combination
of a barium swallow and endoscopy must be pursued if a high suspicion for
esophageal perforation persists despite a negative MDCT.

Blunt injuries
Fig. 3 presents an approach for the diagnostic evaluation of blunt in-
juries. Imaging of the patient who has a blunt neck injury has evolved
with the advent of high-resolution CT. Although lateral soft tissue neck

Fig. 2. Multidetector CT of the neck reveals free air adjacent to the esophagus secondary to
a traumatic perforation (arrows).
684 RATHLEV et al

Blunt Neck Trauma: Vascular and Aerodigestive Injuries

Stable Unstable
Cervical spine immobilize Cervical spine immobilize
Physical Exam – careful neurological exam Secure airway
AP Chest X-ray Blood products for
AP/Lateral soft tissue neck X-ray hemorrhagic shock
High risk injury (Box 3)
Hard signs (Box 2)
Abnormal Soft Signs (Box 1)
Normal

Observe
Serial neurological exams
Abnormal

Multidetector CT angiography
neck and brain

Normal but high

suspicion of vascular Abnormal
or aerodigestive injury

4-Vessel cerebral angiogram Systemic anticoagulation

vs.
Esophagoscopy Stenting
Endoscopy vs.
Surgery
Normal Abnormal

Observe Consider Surgery

Fig. 3. Blunt neck trauma: vascular and aerodigestive injuries.

radiographs are rarely used exclusively to rule out aerodigestive injuries, sig-
nificant injuries can be diagnosed reliably [15]. A chest radiograph remains
a mainstay of the initial trauma workup in assessing for pneumothorax,
hemothorax, and pneumomediastinum.
CT scanning is the initial imaging modality of choice in the hemodynam-
ically stable patient and is used to guide selective operative management.
Chen and colleagues [16] found that CT accurately diagnosed tracheal rup-
ture with deep cervical air in intubated cadavers. Moriwaki studied 3-D
reconstructed CT for diagnosing tracheal injury site. 3-D CT accurately
identified the site of injury, as confirmed by bronchoscopy [17]. In conjunc-
tion with CT, panendoscopy ensures complete evaluation of aerodigestive
injuries.
 EVALUATION AND MANAGEMENT OF NECK TRAUMA 685

Schaefer and Brown [20] developed a classification system for laryngeal

injuries based on a combination of CT scanning and endoscopy (Table 1).
Fiberoptic nasopharyngoscopy for a preliminary assessment of the extent
of trauma and evaluation of vocal cord function, direct laryngoscopy for
a detailed view of the larynx, bronchoscopy to examine the subglottic lar-
ynx, and esophagoscopy for evaluation of esophageal mucosa are all recom-
mended in the workup of blunt neck trauma patients who have signs
of injury. Additionally, barium swallow has been studied for esophageal
injuries. Weigelt and colleagues [19] looked at 118 stable patients who had
cervical trauma and compared barium swallow with endoscopy. All 10
esophageal injuries were identified when the two modalities were combined.
water-soluble radiocontrast agent has replaced barium, but a swallow study
alone does not rule out pharyngoesophageal leak. Before embarking on en-
doscopy, airway patency should be assessed and secured.

Management
Early and rapid airway assessment followed by definitive airway protec-
tion is the key to neck trauma management. The airway must be secured,
and any hemorrhage must be staunched and replaced with blood products.
These principles apply to penetrating and blunt neck injury. Most patients
who have blunt neck trauma are wearing cervical spine collars that compli-
cate the intubation. In-line cervical traction is a safe method for stabilizing
the cervical spine during intubation. The optimal technique for intubating
a patient who has penetrating neck injuries is by direct laryngoscopy,
although it has not been studied at length. It is not clear when a patient
should be observed expectantly for impending airway compromise or
when the patient should be intubated to avoid a situation in which the
anatomy becomes so distorted as to make the procedure more difficult or
impossible leading to an emergent surgical airway. These remain clinical

Table 1
Management of laryngeal trauma
Group Symptoms Signs Management
1 Minor airway symptoms Minor hematoma, no Observation, humidified O2
fracture
2 Airway compromise Edema, mucosal disruption Tracheostomy, direct
laryngoscopy,
esophagoscopy
3 Airway compromise Massive edema, exposed Tracheostomy, exploration/
cartilage, vocal cord repair
immobility
4 Airway compromise Massive edema, exposed Tracheostomy, exploration/
cartilage repair, stent required
686 RATHLEV et al

judgments. Clearly any patient in shock, with hypoxia, or with clear airway
compromise needs immediate intubation.
It is safe to use rapid sequence intubation using a short-acting paralytic
along with an induction agent. In the most recent series in the literature,
100% of 39 patients were successfully intubated using succinylcholine. In to-
tal, 12 patients underwent fiberoptic intubation by otolaryngology clinicians
with 3 failures. Interestingly, those 3 patients were subsequently successfully
intubated using rapid sequence intubation [21]. This example underscores
the vital importance of the clinician using the technique with which he is
most comfortable during emergent airway management. If the airway can
be visualized through the traumatic wound because of tracheal disruption,
it may be possible to intubate the trachea directly through the wound. A sin-
gle case report describes the use of the gum elastic bougie to facilitate the
intubation of a patient who had a self-induced deep slash wound to zone
II and complete tracheal transection. When blind intubation failed, the bou-
gie was used to intubate the trachea, the tracheal rings caused the typical
clicking to confirm the bougie’s location, and the endotracheal tube was suc-
cessfully placed into the trachea over the bougie [22].
There are numerous alternative intubation methods if direct laryngos-
copy fails or cannot be used. Flexible fiberoptic endoscopes can be used
for orotracheal and nasotracheal intubations. These techniques require pa-
tient preparation with topical anesthetics and often intravenous sedation,
and are therefore time consuming and depend on the experience of the op-
erator. Newer rigid fiberoptic endoscopes and videolaryngoscope blades
may aid in finding the vocal cords for intubation, although all of the fiber-
optic methods are difficult to use in the presence of bleeding or heavy
secretions.
Blind nasotracheal intubation historically has been discouraged because
of a perceived high failure rate and potential for complications. A recent
study of 40 patients intubated prehospital demonstrated a 90% success
rate with a similar mortality rate to matched patients who were orotra-
cheally intubated [23]. It is reasonable to consider this a technique in the pre-
hospital setting where emergency orotracheal intubation is not possible. A
surgical airway may be used as a last resort. Cricothyrotomy, or occasion-
ally tracheostomy, is the required procedure because of altered anatomy.
There is a risk that the operator could open an otherwise stable hematoma
while incising through fascial planes and obscure the operative field along
with causing significant hemorrhage.
The wound should be examined with care for degree of penetration, al-
though probing is discouraged because it may inadvertently open a hema-
toma that was otherwise not actively bleeding. Patients who have
progressive subcutaneous or mediastinal emphysema, severe dyspnea requir-
ing intubation, difficulty in mechanical ventilation, uncontrolled hemor-
rhage, or patients who have an air leak from their chest tubes should all
be directed to the operating room for definitive surgical management [24].
 EVALUATION AND MANAGEMENT OF NECK TRAUMA 687

Penetrating injuries to the cervical spine

There are no reports of unstable cervical spine injuries in penetrating
neck trauma by stab wounds. It is a rare individual who may possess the
strength and ferocity to fracture the vertebral column during such an attack,
let alone to create an unstable fracture. Gunshot wounds to the neck would
need to fracture the cervical vertebrae in two columns to create an unstable
fracture. The bullet must traverse the spinal cord to cause this injury, and
the patient presents with neurologic signs. A 14-year study of patients sus-
taining gunshot wounds to the face and neck showed that all patients
who had unstable cervical spine fractures also presented with neurologic
signs [25]. In this study, 3 awake and neurologically intact individuals pre-
sented with gunshot wounds to the face resulting in stable cervical spine
fractures A prior series found no cervical spine injuries in 174 patients
who had gunshot wounds to the head [26]. Based on these results, immediate
urgent treatment of the penetrating neck wound should take precedence
over concerns for the cervical spine, including removing a cervical collar
to gain access to the injury. All patients who have gunshot wounds to the
neck and face should subsequently have a CT of the bony cervical spine
to look for occult fractures, and once the injury has been addressed the col-
lar should be replaced until radiography definitively shows there is no
fracture.
Direct laryngoscopy using a Macintosh or Miller laryngoscope blade
causes minimal movement of the cervical spine in healthy patients posi-
tioned on a rigid board (10–11 degrees of movement) before intubation
[27]. Patients who need to be intubated can be safely managed with in-line
traction and care to keep movement of the neck to a minimum during the
procedure.

Vascular injuries
Epidemiology
Most penetrating neck injuries are caused by knives and low-energy gun-
shot wounds. Fortunately, these weapons impart a low level of kinetic en-
ergy to tissues compared with military rifles and shotguns. The mortality
rate from these injuries is approximately 2% to 6%. The victims are primar-
ily young men who have injuries sustained as a result of interpersonal
violence.
Significant vascular injuries of the neck occur in approximately 1% to
3% of all major blunt trauma victims [28–31]. High-speed motor vehicle ac-
cidents cause most of these injuries [32]. Other mechanisms include motor-
cycle crashes, pedestrians struck by motor vehicles, falls, assaults, and
hangings and near-hangings [33]. Although these injuries are rare, the mor-
bidity and mortality rates are significantly higher than for penetrating
trauma. The overall mortality related to blunt injuries is 20% to 30%; in
688 RATHLEV et al

addition, 37% to 58% of patients develop permanent neurologic deficits at-

tributable to central nervous system ischemia [34].
In blunt trauma, injury to the cervical arteries is likely caused by rapid
deceleration associated with hyperflexion, hyperextension, and rotation.
Vascular structures are stretched over the cervical spine and shearing forces
create intimal tears in the vessel wall [35]. Both blunt and penetrating
vascular injuries result in the formation of pseudoaneurysm, dissection,
arteriovenous fistula, complete transection, and thrombus formation with
occlusion attributable to disruption of atherosclerotic plaque. Stroke in
these patients is believed to be caused by occlusive thromboembolus. Com-
promise of collateral flow is presumably responsible for worse outcomes in
patients who have atherosclerotic vascular disease [36].

Clinical presentation
The challenge for the emergency physician is to detect subtle but signifi-
cant injuries that require intervention. This pertains specifically to patients
who have no immediate indication for operative intervention because of air-
way compromise or hemodynamic instability. The presence of ‘‘hard signs’’
(Box 1) on physical examination indicates a high risk for vascular injury.
Pulse deficit is not a sensitive indicator of significant injury because the
pulses may be normal with nonocclusive injuries, such as an intimal flap
or pseudoaneurysm, that nonetheless require surgical intervention. A bruit
or thrill is pathognomonic of a traumatic arteriovenous fistula that typically
needs surgical repair. ‘‘Soft’’ signs are less predictive of vascular injury and
these are listed in Box 2. Central nervous system ischemia is considered
a soft sign. A primary neurologic injury presents as an immediate deficit,
whereas a neurologic injury caused by ischemia typically becomes evident
over the course of minutes to hours. Proximity to a major vascular structure
is not considered a high-risk feature in the absence of hard signs.
Blunt vascular injuries involving the carotid or the vertebral arteries are
rare and the clinical presentation is often subtle and nonspecific. McKevitt
documented that 60% of blunt cervical injuries were unsuspected at initial
evaluation, and symptoms often were masked by concomitant head or tho-
racic injuries in multiple blunt trauma victims [36]. If identified and treated
early, the likelihood of permanent devastating neurologic dysfunction is

Box 1. Hard signs of vascular injury

Bruit or thrill
Expanding or pulsatile hematoma
Pulsatile or severe hemorrhage
Pulse deficit
 EVALUATION AND MANAGEMENT OF NECK TRAUMA 689

Box 2. Soft signs of vascular injury

Hypotension and shock
Stable, nonpulsatile hematoma
Central or peripheral nervous system ischemia
Proximity to a major vascular structure

decreased. The recognition of symptoms is typically delayed, and almost

25% of patients first develop signs and symptoms 24 hours postinjury. Of-
ten, the initial manifestation of a blunt vascular injury is an acute ischemic
stroke attributable to a thromboembolic event.
The classic presentation is a neurologically intact victim who subse-
quently develops hemiparesis after a high-speed motor vehicle crash. There
are no reliable clinical means with which to diagnose blunt carotid injury be-
fore development of neurologic deficits or stroke [37]. The vast majority of
patients manifest neurologic deficits at the time of diagnosis of blunt carotid
injury [28]. Definitive diagnostic testing should be pursued for patients who
demonstrate any of the high-risk features listed in Box 3. With this
approach, 72% of all blunt vascular injuries can be identified before the on-
set of neurologic deficits [34]. The incidence of blunt vascular injury in pa-
tients who have an ecchymosis from the shoulder seat belt is three times
higher than the incidence in blunt trauma victims in general [31].
Vertebral artery injuries are associated closely with cervical spine injuries
[33]. Some 33% of cervical spine fractures are associated with a vertebral
artery injury after excluding simple spinous process fractures. Fractures
involving the transverse foramen are present in 78% of these patients,
whereas subluxation is associated with most of the remaining injuries. At

Box 3. High-risk criteria to for blunt cerebrovascular injuries

Severe hyperextension or flexion and rotation of neck
Significant soft tissue injury or large hematoma of the anterior
neck
Cervical spine fracture
Seat belt sign across the neck
Massive epistaxis attributable to a carotid-cavernous sinus
fistula,
Bruit or thrill
Stroke or transient ischemic attack
Unexplained neurologic abnormalities
Basilar skull fracture involving the petrous bone
690 RATHLEV et al

least one of these bony injuries is present in 92% of patients who have ver-
tebral artery injury. Bilateral injuries occur in approximately 15% of all pa-
tients [28,34]. Concurrent injuries are common; McKevitt and colleagues
[36] found that almost 95% of patients who had blunt vascular injuries of
the neck had a concomitant major thoracic injury or a Glasgow Coma Scale
score less than 8.

Diagnostic evaluation
Conventional four-vessel cerebral angiogram remains the reference stan-
dard for evaluating the carotid and the vertebral arteries with a sensitivity in
excess of 99%. It provides accurate assessment of the vessels with respect to
the presence of dissection, pseudoaneurysm, occlusion, and transection.
Rarely do injuries missed by angiography require repair and a normal study
is highly predictive of survival from vessel injury [38,39]. Conversely, angi-
ography is invasive, expensive, and resource intensive, and involves mobiliz-
ing interventional radiology. The complication rate is approximately 1%,
usually involving the catheter insertion site or reactions to the intravenous
contrast. Biffl and colleagues [35] developed a classification system for blunt
carotid artery injuries based on the angiographic findings (Table 2). The sys-
tem is successfully used to guide further management.
MDCT angiography has evolved as a sensitive, readily available, and less
invasive diagnostic technique tool for the purpose of assessing patients at
risk. In series of penetrating neck injuries, the sensitivity of MDCT angiog-
raphy is 90% to 100% compared with conventional angiography and surgi-
cal exploration [40,41]. Most patients who meet screening criteria for blunt
vascular injury currently undergo MDCT scanning for other reasons. Add-
ing this technique to clinical evaluation reportedly increased the rate of iden-
tification of injuries by a factor of three, decreased the mean time to

Table 2
Denver grading scale for blunt carotid artery injury
Grade Angiographic findings Prognosis Treatment
I Vessel wall irregularity Good, 7% progress Systemic anticoagulation
or dissection with !25% controversial
of luminal diameter
II Raised intimal flap, Fair with treatment, 70% Systemic anticoagulation
thrombus, dissection, progress
or hematomas O25%
of luminal diameter
III Pseudoaneurysm Require intervention Surgery or stenting
IV Total vessel occlusion Outcome assured at the Systemic anticoagulation
time of diagnosis
V Transection Very poor, high mortality Surgery
Data from Biffl WL, Moore EE, Offner PJ, et al. Blunt carotid arterial injuries: implications
of a new grading scale. J Trauma 1999;47:845–53.
 EVALUATION AND MANAGEMENT OF NECK TRAUMA 691

diagnosis and decreased the rate of permanent neurologic sequelae from ca-
rotid arterial injuries [34]. In comparison with conventional angiography,
MDCT angiography has a sensitivity of 68% and a specificity of 67%.
MDCT angiography missed 55% of grade I injuries, 14% of grade II
injuries, and 13% of grade III Injuries (see Table 2) [42]. The modality
missed 53% of carotid injuries and 47% of vertebral injuries; approximately
one third of the missed injuries were significant lesions, causing stroke in ca-
rotid distribution territory. Higher resolution, 64-slice technology will likely
improve the sensitivity and specificity of MDCT angiography. The modality
is limited by artifacts from metallic fragments and occasionally by abundant
soft tissue air. In such cases, conventional angiography is required for opti-
mal assessment.
Magnetic resonance angiography has shown some promise in assessing
the presence for blunt vascular injury in patients who are hemodynamically
stable and can undergo the procedure. Biffl and colleagues [43] demon-
strated a sensitivity of 75% and specificity of 67%, magnetic resonance an-
giography compared with conventional angiography. Because of a marginal
improvement in sensitivity over MDCT angiography, lack of routine avail-
ability and applicability to the acutely injured patient, magnetic resonance
angiography is unlikely to become a routine screening tool for blunt vascu-
lar injuries of the neck.
Duplex ultrasonography is noninvasive, convenient, and low cost, but the
sensitivity for vascular injury is highly operator dependent. In the hands of
experienced technicians, the sensitivity of duplex ultrasound versus conven-
tional angiography as the reference standard is 90% to 95% for injuries re-
quiring intervention [44]. Duplex ultrasonography can miss nonocclusive
injuries with preserved flow, such as intimal flaps and pseudoaneurysms.
The technique is also limited by the ability to evaluate only the common ca-
rotid and external carotid arteries. Most injuries involve the internal carotid
artery, which is not evaluated well by ultrasound.

Management
Definitive treatment is determined by the angiographic grading of vascu-
lar injury. In general, surgical repair is preferred over ligation except in the
case of coma without antegrade flow. These cases are associated with a high
risk for converting an ischemic to a hemorrhagic brain injury, uncontrolla-
ble hemorrhage, and inability to place a temporary shunt. Primary repair is
preferred over graft placement when possible.
Surgical intervention for blunt injuries is an option for accessible lesions
and includes resection, thrombectomy, and ligation of lesions involving the
common or external carotid. Unfortunately, most blunt injuries involve the
internal carotid artery, which is less accessible. Anticoagulation therapy has
been instituted to reduce morbidity and mortality related to specific grades
of injury to the carotid or vertebral arteries [33]. The grading system for
692 RATHLEV et al

these lesions proposed by Biffl and colleagues group these lesions into cate-
gories based on size, outcome, and treatment options for each (see Table 2).
The rate of subsequent stroke in patients who were initially asymptomatic
has been decreased by as much as 75% when systemic anticoagulation
was instituted. These studies must be interpreted with caution, because
a control group was not included. Some patients were also excluded because
of coexisting traumatic injuries. Antiplatelet therapy has been used when
concurrent injuries present a contraindication to systemic anticoagulation.
Anticoagulation therapy also has proved to be beneficial in patients who
have vertebral artery injuries. When treated with anticoagulation using hep-
arin, aspirin, or aspirin and clopidogrel, neurologically intact patients who
have early detection of blunt vertebral artery injury had a 0% incidence of
stroke [34]. Other studies have similarly found that anticoagulation de-
creases the rate of neurologic morbidity in posterior circulation stroke [33].
Percutaneous angioplasty with stent placement after follow-up angiogra-
phy has been used for the treatment of persistent blunt carotid injuries
[45,46]. This intervention has raised concern regarding the danger of iatro-
genic stroke and has yet to obtain wide acceptance [47,48]. Currently, it
seems that the risks exceed the benefits, especially for carotid artery lesions.

Summary
Early airway management is crucial to successful management of severe
penetrating and blunt neck injuries. Orotracheal intubation is the initial
method of choice; however, no single method is successful 100% of the
time. It is therefore crucial that practitioners are skilled in several different
approaches to airway management, including providing a surgical airway.
In patients who do not have obvious indications for operative intervention
initially, evaluation for hard signs of vascular injury should be pursued.
Hard signs include bruit, thrill, expanding or pulsatile hematoma, pulsatile
or severe hemorrhage, pulse deficit, and central nervous system ischemia. A
high degree of suspicion should be maintained for esophageal injury; unfor-
tunately, radiographs do not exclude esophageal injury and triple endoscopy
is the optimal diagnostic method for the evaluation of aerodigestive injury.
The reference standard for vascular injury is conventional angiography.
MDCT angiography is a noninvasive, less expensive, and more convenient
alternative that is rapidly becoming the diagnostic tool of choice in the eval-
uation of cervical vascular injury caused by penetrating and blunt trauma.

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